Ti-6Al-4V is the most common alloy used for orthopaedic implants. Its popularity is due to low density, superior corrosion resistance, good osseointegration and lower elastic modulus when compared to other commonly used alloys such as CoCrMo and stainless steel. In fact, the use of Ti64 has even further increased lately since recent controversy around adverse local tissue reactions and implant failure related to taper corrosion of CoCrMo alloy. However, implants made from Ti64 can fail in some cases due to fatigue fracture, sometimes related to oxide induced stress corrosion cracking or hydrogen embrittlement, or preferential corrosion of the beta phase. Studies performed with Ti-6Al-4V do often not consider that the alloy itself may have a range of characteristics that can vary and could significantly impact the implant properties. These variations are related to the material microstructure which depends not only on chemical composition, but also the manufacturing process and subsequent heat treatments. Different microstructures can occur in implants made form wrought alloys, cast alloys, and more recently, additive manufactured (AM) alloys. Implant alloy microstructure drives mechanical and electrochemical properties. Therefore, this study aims to analyse the microstructure of Ti-6Al-4V alloy of additive manufactured and conventional retrieved orthopaedic implants such as acetabular cups, tibial trays, femoral stem and modular neck by means of electron backscatter diffraction (EBSD). Microstructural features of interest include grains shape and size, phase content and distribution, preferred grain orientation (texture), alloying elements distribution (homogenization) and presence of impurities. Additionally, we demonstrate the direct impact of different microstructural features on hardness. We analysed 17 conventional devices from 6 different manufacturers, 3 additive manufactured devices from 2 different manufactures and 1 control alloy (bar stock). The preliminary results showed that even though all implants have the same chemical composition, their microstructural characteristics vary broadly. Ti64 microstructure of conventional alloys could be categorized in 3 groups: equiaxed grains alloys (Fine and Coarse), bimodal alloys and dendritic alloys. The additive manufactured implants were classified in an additional group on its own which consists of a needle-like microstructures - similar to Widmanstätten patterns, Fig. 1, with a network of β phase along α phase grains. Furthermore, AM alloys exhibited residual grain boundaries from the original β grains from the early stage of the solidification process, Fig. 2. These characteristics may have implication on the fatigue and corrosion behaviour. In addition, it we observed inhomogeneous alloying element distribution in some cases, Fig. 3, especially for the additive manufactured alloys, which also may have consequences on corrosion behaviour. Finally, the hardness testing revealed that the implants with large grain size, such as AM alloys, exhibit low hardness values, as expected, but also the amount of beta phase correlated positively with lower hardness. Grain aspect ratio and beta phase grain size correlated positively with higher hardness. In summary, we found that common Ti64 implants can exhibit a broad variety of different alloy microstructures and the advent of AM alloys introduces an entirely new category. It is imperative to determine the ideal microstructure for specific applications.

Little is known about the relationship between head-neck corrosion and its effect on the periprosthetic tissues and distant organs of patients hosting well-functioning devices. The purpose of this study was to investigate in postmortem retrieved specimens the degree and type of taper damage, and the corresponding histologic responses in periprosthetic tissues and distant organs.

Fifty postmortem THRs (34 primaries, 16 revisions) retrieved after 0.5 to 26 years were analyzed. Forty-three implants had a CoCrMo stem and seven had a Ti6Al4V stem. All heads were CoCrMo and articulated against polyethylene cups (19 XLPE, 31 UHMWPE). H&E sections of joint pseudocapsules, liver, spleen, kidneys and lymph nodes were graded 1–4 for the intensity of various inflammatory cell infiltrates and tissue characteristics. Corrosion damage of the taper surfaces was assessed using visual scoring and quantitated with an optical coordinate measuring machine. SEM analysis was used to determine the acting corrosion mode. Polyethylene wear was assessed optically. The majority of tapers had minimal to mild damage characterized by local plastic deformation of machining line peaks. Imprinting of the stem topography onto the head taper surface was observed in 18 cases. Column damage on the head taper surface occurred in three cases. All taper surfaces scored moderate or severe exhibited local damage features of fretting and/or pitting corrosion.

Moderate or severe corrosion of the head and/or trunnion was present in nine hips. In one asymptomatic patient with bilateral hips, lymphocyte-dominated tissue reactions involving perivascular infiltrates of lymphocytes and plasmacytes were observed. In this patient, mild, focal lymphocytic infiltrates were also present in the liver and kidneys, and there was focal histiocytosis and necrosis of the para-aortic lymph nodes. These two implants, which had been in place for 58.6 and 60.1 months, had severe intergranular corrosion of the CoCrMo trunnion, and column damage and imprinting on the head taper. In the other 41 hips, macrophage responses in the joint pseudocapsule to metallic and/or polyethylene wear particles ranged widely from minimal to marked. Focal necrosis in the pseudocapsules of 12 arthroplasties was related to high concentrations of CoCrMo, TiAl4V, TiO, BaSO4 and polyethylene wear particles. High concentrations of these particles were also detected in para-aortic lymph nodes. Rare to mild macrophages were observed in liver and spleen.

This is a comprehensive study of wear and corrosion within well-functioning postmortem retrieved THRs, and the resulting local and distant tissue reactions. One of eight patients with moderate or severe corrosion did have a subclinical inflammatory response dominated by lymphocytes after five years. To what extent such an inflammatory process might progress to become symptomatic is not known. Ionic and particulate products generated by corrosion disseminated systemically. The minor lymphocytic infiltrate in the liver and kidneys of one subject with bilateral severely corroded head-neck junctions might suggest possible metal toxicity. The diagnosis of adverse tissue reactions to corrosion of modular junctions can be challenging. Postmortem retrieval studies add to our understanding of the nature and progression of lymphocyte-dominated adverse local and potentially systemic tissue reactions to corrosion of modular junctions.

Introduction

Total hip arthroplasty (THA) is a commonly performed procedure to relieve arthritis or traumatic injury. However, implant failure can occur from implant loosening or crevice corrosion as a result of inadequate seating of the femoral head onto the stem during implantation. There is no consensus—either by manufacturers or by the surgical community—on what head/stem assembly procedure should be used to maximize modular junction stability. Furthermore, the role of “off-axis” loads—loads not aligned with the stem taper axis—during assembly may significantly affect modular junction stability, but has not been sufficiently evaluated.

Wear and corrosion debris generated from total hip replacements (THR) can cause adverse local tissue reactions (ALTR) or osteolysis, often leading to premature implant failure. The tissue response can be best characterized by histopathological analysis, which accurately determines the presence of cell types, but is limited in the characterization of biochemical changes (e.g. protein conformation alteration). Fourier transform infrared micro-spectroscopy imaging (FTIRI) enables rapid analysis of the chemical structure of biological tissue with a high spatial resolution, and minimal additional sample preparation. The data provides the most information through multivariate method carried out by hierarchical clustering analysis (HCA).

It is the goal of this study to demonstrate the beneficial use of this multivariate approach in providing pathologist with biochemical information from cellular and subcellular organization within joint capsule tissue retrieved from THR patients.

Joint capsule tissue from 2 retrieved THRs was studied. Case 1: a metal-on-polyethylene THR, and Case 2: a dual modular metal-on-metal THR. Prior to FTIRI analysis, tissue samples were formalin-fixed paraffin-embedded and 5μm thick microtome sectioned samples were prepared and mounted on BaF₂ discs and deparaffinized. FTIRI data were collected using high-definition transmission mode (pixel size: ∼1.1 μm²). Hyperspectral images were exported to CytoSpec V2.0.06 for processing and reconstruction into pseudo-color maps based on cluster assignments.

Case 1 exhibited a strong presence of lymphocytes and macrophages (Fig. 1a). Since the process of taking second derivatives reduces the half width of the spectral peaks, it increases the sensitivity toward detecting shoulders or second peaks that may not be apparent in the raw spectra (Fig. 1b). Thus, areas occupied by lymphocytes and macrophages can be easily distinguished providing a fast tissue screening method. Here, HCA was able to distinguish macrophages and lymphocytes based on the infrared response, even in areas where both occurred intermixed. (Fig. 1c) The tissue in direct proximity to cells had a slightly altered collagenous structure. Case 1 also exhibited multiple glassy, green particles which can typically observed around THRs that underwent taper corrosion (Fig. 2a). HCA image was able to visualize and distinguish large CrPO₄ particles, embedded within fibrin exudate rich areas, collagenous tissue without inflammatory cells, and a nearby area with a strong macrophage presence and some finer CrPO₄ particles (Fig. 2d). Moreover, this method can not only locate macrophages, but distinguish particle-laden macrophages depending the type of particles within the cells. In Case 2 (Fig. 3a), clustering results (Fig. 3 b&c) are consistent with the fact that different particle types are associated with MoM bearing surface wear (Co rich particles), corrosion of the CoCrMo taper junctions (Cr-oxides and –phosphate), fretting of Ti-alloy dual modular tapers (Ti-oxides, Ti alloy particles), and even suture debris, which all occurred in this case. Although details of debris types are not available, specifications are possible by coupling other techniques.

The results demonstrate that multivariate FTIRI based spectral histopathology is a powerful tool to characterize the chemical structure and foreign body response within periprosthetic tissue, thus providing insights into the biological impact of different types of implant debris.

For any figures or tables, please contact the authors directly.

Introduction

The combined incidence of anatomic (aTSA) and reverse total shoulder arthroplasties (rTSA) in the US is 90,000 per annum and rising. There has been little attention given to potential long-term complications due to periprosthetic tissue reactions to implant debris. The shoulder has been felt to be relatively immune to these complications due to lower acting loads compared to other joint arthroplasties. In this study, retrieved aTSAs and rTSAs were examined to determine the extent of implant damage and to characterize the nature of the corresponding periprosthetic tissue responses.

INTRODUCTION

The lifetime of total hip replacements (THR) is often limited by adverse local tissue reactions to corrosion products generated from modular junctions. Two prominent damage modes are the imprinting of the rougher stem topography into the smoother head taper topography (imprinting) and the occurrence of column-like troughs running parallel to the taper axis (column damage). It was the purpose of this study to identify mechanisms that lead to imprinting and column damage based on a thorough analysis of retrieved implants.

Introduction

Little is known about the relationship between head-neck corrosion and its effect on periprosthetic tissues and distant organs in the majority of patients hosting apparently well-functioning devices. We studied the degree and type of taper damage and the histopathologic response in periprosthetic tissue and distant organs.

Recently, corrosion at the head-neck junction in metal-on-polyethylene bearing total hip arthroplasty (THA) has been recognized as a cause of adverse local tissue reactions (ALTR). Serum metal levels have been advocated as a tool for the diagnosis of ALTR, however no prior studies have specifically examined their utility. The purpose of this study was to determine the optimal cut-off values for serum cobalt and chromium in diagnosing ALTR after metal-on-polyethylene bearing THA.

We reviewed 447 consecutive patients with serum metal levels tested at our institution and identified 62 with a metal-on-polyethylene bearing who had axial imaging or underwent reoperation to confirm the presence or absence of ALTR. Receiver operating characteristic curves were produced to identify cut-off thresholds to optimize sensitivity and diagnostic test performance was characterized.

42 Of the 62 patients (66%) were positive for an ALTR. The best test for the diagnosis of ALTR was the serum cobalt level (area under the curve [AUC]=99%). A threshold cut-off of ≥ 1.0 ng/ml had a sensitivity of 100%, specificity of 90%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 100%. Serum chromium levels were also diagnostic (AUC=87%). A threshold cut-off of ≥ 0.15 ng/ml had a sensitivity of 100%, specificity of 50%, PPV of 81%, and NPV of 100%. Finally, serum cobalt to chromium ratio was also helpful for diagnosis (AUC=90%). A threshold cut-off of 1.4 for the cobalt to chromium ratio offered a sensitivity of 93%, specificity of 70%, PPV of 87%, and NPV of 82%.

Measurement of serum cobalt with a threshold value of 1.0 ng/ml in our experience is the best test for identifying the presence of ALTR in patients with a metal-on-polyethylene THA. Measurement of chromium and the ratio of cobalt to chromium are also of value.

Introduction

There are increasing reports of total hip replacement (THR) failure due to corrosion within modular taper junctions, and subsequent adverse local tissue reactions (ALTRs) to corrosion products. Modular junction corrosion is a multifactorial problem that depends on material, design, patient and surgical factors. However, the influence of alloy microstructure on corrosion has not been studied sufficiently. Especially for cast CoCrMo, there are concerns regarding microstructure variability with respect to grain size and hard-phase volume fraction. Therefore, it was the goal of this study to (1) identify different types of microstructures in contemporary implants, and (2) determine implications of alloy microstructure on the occurring corrosion modes.

Anterior lumbar interbody fusion (ALIF) is an accepted surgical treatment for disabling discogenic pain. Additional posterior fixation has been advocated. This is a prospective clinic al study evaluating a stand-alone anterior fusion cage with an integrated titanium plate and four divergent locking screws.

Patients who had failed conservative management for lumbar discogenic pain were recruited into the study. All underwent diagnostic discography. Surgery was performed through an anterior retro-peritoneal approach. The fusion cage was packed with autogenous bone graft. Outcome measures included: Visual Analogue Scores (VAS), Oswestry Disability Index (ODI) and SF-36 data. Fine-cut CT was performed at one and two years post-operatively. Fusion was defined as continuous bony trabeculae joining the vertebral bodies.

Fifty levels were operated on in 39 patients with a mean age of 40.8 years (22–55). The mean operative time was less than 120 minutes, and mean blood loss less than 100 mls. Radiographic fusion at one year was 78% and 100% at two years. Two year mean VAS sc ores for back pain improved from 7.0 to 3.7 (p< 0.01) and for leg pain from 6.1 to 3.1 (p< 0.01). The mean ODI scores decreased from 50.7 to 31.7 (p< 0.01), and SF-36 (PCS) scores increased from 28.4 to 37.5 (p< 0.01). There were no major complications and no patients have required supplementary posterior fixation.

This technique is safe and is as effective as 360° fusion in achieving fusion in the management of discogenic back pain over one and two levels. This technique has the advantage of avoiding the morbidity associated with additional posterior fixation.

Introduction: Epidural steroid injection is commonly used for treatment of sciatica. Traditionally these have been administered through a needle inserted in the posterior mid line via an interlaminar (IL) route. However, in recent years the transforaminal (TF) route of administration has become popular. Potential advantages of the TF route include greater accuracy of injection (with radiological confirmation) and placement of the needle tip closer to the point at which the nerve is compressed.

Methods: Consecutive patients from the practices of 2 surgeons that use an IL technique were compared with those from the practices of 2 other surgeons that use a TF technique. Inclusion criteria were leg pain accompanied by a radiological diagnosis of nerve root compression. Both patients with disc prolapse and spinal stenosis were included. Treatment outcome was measured using the Roland-Morris (RM) Score, the Sciatica Frequency and Bothersome Index (SFBI) and the Euroqol (EQ-5D) questionnaire obtained at recruitment and three months after the epidural steroid injection. A global assessment (GA) of outcome; where patients were asked whether they were

much better,

Patients were also asked the duration of any relief obtained. Statistical methods utilized included the two tailed t-test, the Wilcoxon Rank Sum test, Odds ratio (OR) and the Chi Squared Test.

Results: 39 patients received an interlaminar epidural steroid injection and 25 received a transforaminal epidural steroid injection (total 64 patients). Follow-up was achieved for 36/39 (92.3%) and 25 (100%) patients respectively. The median pre-test RM score was 11 (range 3–11) for both groups. Post test RM score was 12(6–16) for the IL group and 3 (6–10.5) for the TF group (p=0.01). Median pre-test SFBI was 25 (0–46) and 26 (4–46) for the IL and TF groups respectively. Post test SFBI was 22 (0–46) and 18 (0–41) for the IL and TF groups respectively (p=0.003). Median pre- test EQ-5D was 0.54 for both groups (range 0.06–0.72 for the IL group and 0.08–0.72 for the TF group). Post test EQ-5D was 0.55 (0.06–1) for the IL group and 0.66 (0.06–1) (p=0.21). According to their GA, 11.1% felt much better, 33.3% felt better and 55.6% felt unchanged at 3 months in the IL group. 64% felt much better, 34% better and 12% felt unchanged in the transforaminal group. The proportion of patients having relief for 3 months or more after the injections was 3/36 (8.3%) for the IL group and 10/25 (40%) for the TF group. The transforaminal injection was 7 times more likely to result in pain relief at 3 months. (OR 7.3 95% CI 1.5 – 45.8, p=0.003).

Discussion: Epidural steroid injection by the transforaminal route is more effective then by the interlaminar route in the short term relief of sciatica.

Introduction: Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but there are no published randomized controlled trials assessing efficacy against a placebo group.

Methods: Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed conservative treatment were considered for the study. Inclusion criteria included one or two level symptomatic internal disc disruption as determined by provocative CT/discography. Patients were excluded if there was > 50% loss of disc height or had had previous back surgery. Fifty-seven patients were randomized with a 2:1 (IDET: Placebo) ratio, 38 to the active IDET arm and 19 to the sham (placebo). The IDET catheter was positioned under sedation to cover at least 75% of the annular tear as defined by the CT/discogram. An independent technician connected the catheter to the generator and either delivered electrothermal energy (active group) or did not (sham group). Surgeon, patient and independent outcome assessor were all blinded. All patients followed a standard rehabilitation programme.

Outcome Measures: Low Back Outcome Score (LBOS), Oswestry Disability Index (ODI), SF-36 questionnaire, Zung Depression Index (ZDI) and Modified Somatic Perceptions Questionnaire (MSPQ) were measured at baseline and 6 months. Successful outcome was defined as: No neurological deficit resulting from the procedure, improvement > 7 points in LBOS, improvements > 7 points in SF-36 subsets (pain / disability, physical functioning and bodily pain)

Results: Two subjects withdrew from the study (both IDET). Baseline demographic data, employment and worker’s compensation status, sitting tolerance, initial LBOS, ODI, SF-36, ZDI and MSPQ were similar for both groups. No neurological deficits occurred as a result of either procedure. No subject in either treatment arm showed improvement of > 7 points in LBOS or the specified domains of the SF-36. Mean ODI was 41.4 at baseline and 39.7 at 6 months for the IDET group compared to 40.7 at baseline and 41.5 at six months for the Placebo group. There was no significant change in ZDI or MSPQ scores for either group.

Discussion: No subject in either treatment arm met criteria for successful outcome. There was no significant change in outcome measures in either group at six months. This study demonstrates no significant benefit from IDET over placebo.

Introduction and Aims: Trans-laminar screw fixation is a popular method of posterior stabilisation when performing a 360-degree lumbar fusion, but many have concerns over the biomechanical stability of this construct. The objective of this paper is to compare the fusion rate and clinical outcome of this method with pedicle screw fixation.

Method: During 2001, 31 patients underwent combined anterior and posterior fusion by the two senior surgeons for the treatment of discogenic low back pain. Anterior interbody fusion was performed using the Syncage LR in all patients. Sixteen patients underwent trans-laminar screw fixation posteriorly and 15 underwent pedicle screw fixation. Fusion was assessed by fine cut CT scan at one year post-operatively. Function was assessed with pre- and post-operative Low Back Outcome Score and visual analogue pain scores.

Results: The average follow-up was 15.5 months. The incidence of pseudarthrosis in the trans-laminar screw group was approximately 80% (15 out of 19 levels), compared to 20% (4 of 21 levels) in the pedicle screw group (p < 0.05). There were trends towards greater improvements in the LBOS and VAS scores in the pedicle screw group. There were two surgical complications in the trans-laminar screw group and one in the pedicle screw group

Conclusion: The use of trans-laminar screws is associated with a significantly higher rate of pseudarthrosis compared to pedicle screw fixation. Assessing fusion with fine cut CT scans has revealed a higher rate of pseudarthrosis with trans-laminar screw fixation than has previously been reported

Introduction Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but to date there are no published randomized controlled trials assessing efficacy versus a placebo group.

Methods Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed to improve with conservative therapy were considered. Inclusion criteria included the presence of one or two level symptomatic disc degeneration with posterior or postero-lateral annular tears as determined by provocative CT/discography. Patients were excluded if there was > 50% loss of disc height or previous back surgery. Fifty-seven patients were randomized with a 2:1 (IDET: Placebo) ratio, 38 to the active IDET arm and 19 to the sham procedure (placebo). In all cases the IDET catheter was positioned under sedation to cover at least 70% of the annular tear defined by the CT/discogram. An independent technician connected the catheter to the generator and either delivered electrothermal energy (active group) or did not (sham group). Both surgeon and patients were blinded to the treatment. Patients followed a standard post-procedural rehabilitation programme. Low Back Outcome Score (LBOS), Oswestry Disability Index (ODI), SF-36 questionnaire, Zung Depression Index (ZDI) and Modified Somatic Perceptions Questionnaire (MSPQ) were measured at baseline and six months. Successful outcome was defined as: no neurological deficit resulting from the procedure, improvement in LBOS of > 7 points, improvements in SF-36 subsets (pain/disability, physical functioning and bodily pain). Two subjects withdrew from the study (both IDET). Baseline demographic data, employment and workers’ compensation status, sitting tolerance, initial LBOS, ODI, SF-36, ZDI and MSPQ were similar for both groups.

Results No neurological deficits occurred as a result of either procedure. No subject in either treatment arm showed improvement of > 7 points in LBOS or specified domains of the SF-36. Mean ODI was 41.4 at baseline and 39.7 at six months for the IDET group compared to 40.7 at baseline and 41.5 at six months for the placebo group. There was no significant change in ZDI or MSPQ scores for either group. No subject in either treatment arm met criteria for successful outcome. Further analysis showed no significant change in outcome measures in either group at six months.

Conclusions This study demonstrates no significant benefit from IDET over placebo.

Introduction: 360 degree combined anterior and posterior fusion is an accepted surgical treatment for the management of discogenic back pain. Controversy exists to the optimal technique of posterior fixation. Proponents of translaminar screw fixation cite lower morbidity as a result of less dissection. Despite reports of high fusion rates with this technique, there are concerns over the biomechanical inferiority of this construct compared to pedicle screw fixation. Previous studies on translaminar screws have used only plain radiographs to assess fusion. The objective of this paper is to compare radiographic outcomes, using high definition CT scans, and clinical outcomes between these two methods of posterior fixation.

Methods: During 2001, 31 patients underwent combined anterior and posterior fusion by the two senior surgeons for the management of back pain. Anterior interbody fusion was performed using the Syncage in all patients. 16 patients underwent translaminar screw posterior fixation and 15 underwent pedicle screw posterior fixation. Fusion was assessed by high definition CT scan at one year postoperatively. Function was assessed with pre- and postoperative Low Back Outcome Score and visual analogue scores.

Results: Minimum follow-up was 12 months. The incidence of pseudarthrosis in the translaminar group was over 75% which was five times greater than that seen in the pedicle screw group (p = 0.01). There were trends towards greater improvements in the LBOS and VAS scores in the pedicle screw group and amongst those patients who achieved a successful fusion. There were two surgical complications in the translaminar screw group and one in the pedicle screw group.

Discussion: With the numbers that are available, there are no clinical differences between the two methods of fixation, although there were trends towards improved function and reduced pain in the pedicle screw group. Furthermore there does not appear to be any difference in regards to complications. However, translaminar screws are associated with a significantly higher rate of pseudarthrosis compared to pedicle screws.

INTRODUCTION: Intra-Discal Electrothermal Therapy (IDET) has been proposed as a treatment for chronic discogenic low back pain. Reports from prospective outcome studies demonstrate statistically significant improvements, but to date there are no published randomised controlled trials assessing efficacy versus a placebo group.

METHODS: Ethical committee approval was obtained prior to the study. Patients with chronic low back pain who failed to improve with conservative therapy were considered for the study. Inclusion criteria included the presence of one or two level symptomatic disc degeneration with posterior or posterolateral annular tears as determined by provocative CT/discography. Patients were excluded if there was > 50% loss of disc height or previous back surgery. Fifty-seven patients were randomised with a 2:1 (IDET: Placebo) ratio, 38 to the active IDET arm and 19 to the sham procedure (placebo). In all cases the IDET catheter was positioned under sedation to cover at least 70% of the annular tear defined by the CT/ discogram. An independent technician connected the catheter to the generator and either delivered electrothermal energy (active group) or did not (sham group). Both surgeon and patient were blinded to the treatment. Patients followed a standard post-procedural rehabilitation programme.

OUTCOME MEASURES: Low Back Outcome Score (LBOS), Oswestry Disability Index (ODI), SF-36 questionnaire, Zung Depression Index (ZDI) and Modified Somatic Perceptions Questionnaire (MSPQ) were measured at baseline and six months. Successful outcome was defined as: No neurological deficit resulting from the procedure, improvement in LBOS of > 7 points, improvements in SF-36 subsets (pain/disability, physical functioning and bodily pain)

RESULTS: Two subjects withdrew from the study (both IDET). Baseline demographic data, employment and worker’s compensation status, sitting tolerance, initial LBOS, ODI, SF-36, ZDI and MSPQ were similar for both groups.

No neurological deficits occurred as a result of either procedure. No subject in either treatment arm showed improvement of > 7 points in LBOS or specified domains of the SF-36. Mean ODI was 41.4 at baseline and 39.7 at six months for the IDET group compared to 40.7 at baseline and 41.5 at six months for the Placebo group. There was no significant change in ZDI or MSPQ scores for either group.

DISCUSSION: No subject in either treatment arm met criteria for successful outcome. Further analysis showed no significant change in outcome measures in either group at six months. This study demonstrates no significant benefit from IDET over placebo.

INTRODUCTION: 360 degree combined anterior and posterior fusion is an accepted surgical treatment for the management of discogenic back pain. Controversy exists to the optimal technique of posterior fixation. Proponents of translaminar screw fixation cite lower morbidity as a result of less dissection. Despite reports of high fusion rates with this technique, there are concerns over the biomechanical inferiority of this construct compared to pedicle screw fixation. Previous studies on translaminar screws have used only plain radiographs to assess fusion. The objective of this paper is to compare radiographic outcomes, using high definition CT scans, and clinical outcomes between these two methods of posterior fixation.

METHODS: During 2001, 31 patients underwent combined anterior and posterior fusion by the two senior surgeons for the management of back pain. Anterior interbody fusion was performed using the Syncage in all patients. 16 patients underwent translaminar screw posterior fixation and 15 underwent pedicle screw posterior fixation. Fusion was assessed by high definition CT scan at one year post-operatively. Function was assessed with pre- and post-operative Low Back Outcome Score and visual analogue scores.

RESULTS: Minimum follow-up was 12 months. The incidence of pseudarthrosis in the translaminar group was over 75% which was five times greater than that seen in the pedicle screw group (p = 0.01). There were trends towards greater improvements in the LBOS and VAS scores in the pedicle screw group and amongst those patients who achieved a successful fusion. There were two surgical complications in the translaminar screw group and one in the pedicle screw group.

DISCUSSION: With the numbers that are available, there are no clinical differences between the two methods of fixation, although there were trends towards improved function and reduced pain in the pedicle screw group. Furthermore there does not appear to be any difference in regard to complications. However, translaminar screws are associated with a significantly higher rate of pseudarthrosis compared to pedicle screws.

This paper reports a high incidence of minor congenital anomalies in boys and girls with Perthes' disease compared with that in a control population. There is a similarity of the incidence of minor anomalies in the children with Perthes' disease to that in babies with a single major congenital defect. Multiple major defects were more numerous and more severe than in the control children. It is speculated that there may be a congenital abnormality affecting skeletal development which in some way makes the hip susceptible to Perthes' disease at a later date.